Record No.

Inspection & Test Record for Sewers

Client:

Subcontractor:

Project No.:

Subcontract P.O. No.:

Project Name:

System:

Reference Document:

Items to Inspect
Pipelines

1.0

Excavation

2.0

De-watering

3.0

Bedding

4.0

Material of pipe

5.0

Diameter of pipe

6.0

Elev. invert charge

7.0

Ele. invert
discharge

8.0

Connection pipe
sections

9.0

Connection pipemh

10.0

Hydrostatic teststate durations

from
to

11.0

Backfill

from mh ...

from mh ...

from mh ...

to mh ...

to mh ...

to mh ...

s/c

Company

Init/Date

Init/Date

s/c

Company

Init/Date

Init/Date

from mh ...
to mh ...

s/c

Company

Init/Date

Init/Date

s/c

Company*

Init/Date

Init/Date

Proctor test Y/N

12.0

Miscellaneous

H = Companys presence is mandatory for all activities in section.

Attachments, No. of pages:

h = Companys presence is mandatory

Remarks:
Accepted for Subcontractor
name:

signature:
date:

Accepted for Company

name:

signature:

C:\RB_Forms\RB26J11.DOT\

date:

Accepted for Client

name:

signature:

date:

*Company only initial holdpoint

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